Character, Incidence, and Predictors of Knee Pain and Activity After Infrapatellar Intramedullary Nailing of an Isolated Tibia Fracture

Can Anterior Knee Pain Be Explained by Patella Position After Infrapatellar Tibia Intramedullary Nailing?

OBJECTIVE

The objective of this study is to investigate the postoperative position of the patella and its relationship with anterior knee pain in patients operated with infrapatellar reamed tibia intramedullary nailing (IMN).

MATERIALS AND METHODS

 Patients who underwent tibia IMN between 2019 and 2022 and who had anterior knee pain in their postoperative follow-up at least two outpatient clinic controls with an interval of at least one month were examined. Patellar height indices (Insall-Salvati, Blackburne-Peel, Caton-Deschamps, and modified Insall-Salvati) and sagittal angulation (patella-patellar tendon angles) were measured on the lateral direct radiographs of the patients in semi-flexion. As a control group, measurements were made on the contralateral intact extremity radiographs of the same patients.

RESULTS

 There was no significant difference in patellar height indices between the fractured and intact sides in any of the patients (p = 0.588; p = 0.747; p = 0.446; p = 0.573, respectively). When the sagittal angulations were analyzed, a significant difference was found between the fractured and intact sides of the patients (p = 0.048), resulting in an approximate three-degree change.

CONCLUSION

 Patellar sagittal balance has been identified as one of the contributing factors to the development of anterior knee pain following reamed tibial IMN. Further biomechanical and comprehensive clinical studies are needed on this subject.

Investigating and defining outcomes of suprapatellar versus infrapatellar intramedullary nailing of tibial shaft fractures: a protocol for a pilot randomised controlled trial

Background

Anterior knee pain is often reported following intramedullary nailing of tibial shaft fractures. The aetiology remains unclear, but the surgical approach may play an important role. To date, no biomechanically validated method exists to assess patient outcomes specific to anterior knee pain in this cohort. The central aims of this study are to (1) evaluate the feasibility of a full-scale randomised controlled trial (RCT) investigating the influence of surgical approach on intramedullary nailing of tibial shaft fractures (suprapatellar versus infrapatellar nailing), (2) explore differences in clinical outcomes between the approaches, and (3) explore the development of a biomechanically validated methodology for assessing post-operative anterior knee pain and knee function specific to intramedullary nailing of tibial shaft fractures.

Methods

This pilot study will follow a prospective randomised controlled design at the Royal Adelaide Hospital and The Queen Elizabeth Hospital (South Australia). This study aims to recruit 60 patients between 18 and 60 years old who will be randomly assigned to either the suprapatellar or infrapatellar approach following a decision for intramedullary surgical fixation by the treating surgeon. All nails in this study will be Stryker T2 Alpha nails. Patients will undergo standard radiograph, magnetic resonance imaging, and clinical assessments in-line with their standard operative care, and complete a number of patient-reported and performance-based outcome measures. Performance-based outcome measures will be assessed utilising three-dimensional motion capture techniques. Follow-up time points are 3, 6, 12, and 18 months. Feasibility outcomes include ability to meet enrolment and retention metrics, compliance with all questionnaires and assessment procedures, and the occurrence of any adverse events. The primary clinical outcome is the incidence of anterior knee pain at 12 months after surgery.

Discussion

This study will establish the feasibility and inform the design of a large-scale RCT. Evaluation of all clinical data and patient outcomes will lead to the development of a new tool for assessing patient outcomes in this cohort. Limitations of the study include an unpredictable enrolment rate and loss to follow-up, small sample size, and the unknown ability of three-dimensional motion analysis to pick up the effects of anterior knee pain after tibial nailing.

Trial registration

This trial was prospectively registered on the 7 February 2020 on ANZCTR, ACTRN12620000109909.

Rates and timing of short-term complications following operative treatment of tibial shaft fractures

Introduction

Tibial shaft fractures are a relatively common injury in orthopaedic surgery, with management options including intramedullary nail (IMN) fixation or open reduction internal fixation (ORIF) with plate osteosynthesis. Using a large national database, we sought to compare the prevalence and timing of short-term complications following either IMN or ORIF for tibial shaft fractures.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients undergoing IMN or ORIF for the treatment of tibial shaft fracture between 2012 and 2018. Multivariate Poisson hurdle regression models were utilized to determine predictors of postoperative complications as well as the timing of postoperative complications.

Results

A total of 4963 tibial shaft fracture were identified, with 3601 patients undergoing IMN (72.6%) and 1362 undergoing ORIF (27.4%). Patients undergoing IMN had a lower mean age of 48.8 compared with 53.9 for plate osteosynthesis (P < .001). IMN patients were also more likely to be male (53.5%) compared with ORIF patients (44.2%, P < .001). In multivariate analysis, ORIF patients were significantly more likely to experience surgical site complications, including dehiscence, superficial, and deep infections (OR 2.04, P = .003). There was no difference in probability of VTE between constructs; however, patients who underwent ORIF were diagnosed with VTE earlier than those who underwent IMN (relative rate 0.50, P < .001). There was no difference between ORIF and IMN with regard to probability or timing of subsequent blood transfusion, major complications, or return to the operating room. Many patient factors, such as higher American Society of Anesthesiologists score, congestive heart failure, and hypertension, were independently associated with an increased risk of postoperative complications.

Conclusions

Postoperative complications within 30 days are common after the surgical treatment of tibial shaft fractures. The risk of developing specific complications and the timing of these complications vary depending on numerous factors, including potentially modifiable risk factors such as the method of fixation or operative time, as well as nonmodifiable risk factors such as medical comorbidities.

Effects of morphological changes in the patellar tendon on the development of anterior knee pain after intramedullary nailing for tibial shaft fractures: A retrospective comparative study

OBJECTIVE

This study aimed to investigate the effects of morphological changes of the patellar tendon (length, width, and thickness) on the development of anterior knee pain (AKP) after intramedullary nailing (IMN) of tibial shaft fractures.

METHODS

A total of 39 patients, treated by IMN using the transpatellar approach for tibial shaft fractures, were retrospectively reviewed and included in the study. The patients were then divided into 2 groups based on the presence of AKP: group A, patients who developed AKP (9 men, 9 women; mean age=35.39±9.32 years), and group B, patients without AKP (13 men, 8 women; mean age=41.38±14.78 years). To assess the morphological changes in the patellar tendon, magnetic resonance imaging was performed on the operated and unoperated, contralateral knees of the patients. The patellar tendon index (PTI) was calculated using the length, width, and thickness of the patellar tendon, and a set of variables was established to be a proportion of the measurements of the operated knees to those of the unoperated ones (operated/healthy PTI ratio). PTI ratios were compared between both the groups. Furthermore, the morphological features of the patellar tendon, including the length, width, and thickness, were examined within the groups as independent variables. To assess pain intensity in group A, a 10-cm visual analogue scale (VAS) was used. To evaluate functional status, the Lysholm knee scoring system was used.

RESULTS

The PTI ratio was significantly higher in group A (1.37±0.12) than in group B (1.03±0.08) (p<0.001). In group A, the mean VAS score was 5.35±1.11, and a moderate linear correlation was found between PTI ratios and VAS scores (r=0.494, p=0.044). The mean Lysholm score was significantly lower in group A (80.17±3.05) than in group B (89.76±3.05) (p<0.001). In group A, the width and thickness of the patellar tendon were found to be significantly different between the operated and unoperated knees (p=0.024 and p=0.002, respectively). In group B, there was no difference between the operated and unoperated knees in terms of the 3 measurements (length, width, and thickness) (p=0.762, p=0.753, and p=0.118, respectively).

CONCLUSION

Evidence from this study revealed that morphological changes occurring in the patellar tendon after IMN for tibial shaft fractures using a transpatellar approach may have a significant role in the development of AKP. The increase in the tendon width and thickness may be the cause of pain and insufficient knee function in such patients.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre

Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach. Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 - 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores. Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1). Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.

Incidence of Knee Pain Beyond 1 Year: Suprapatellar Versus Infrapatellar Approach for Intramedullary Nailing of the Tibia

OBJECTIVE

To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury.

DESIGN

Retrospective cohort study.

SETTING

Academic Level I trauma center.

PATIENTS/PARTICIPANTS

All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours.

INTERVENTION

Intramedullary nailing of a tibia fracture with either the SP or IP approach.

MAIN OUTCOME MEASUREMENTS

Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful.

RESULTS

The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45).

CONCLUSIONS

In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonoperative Management of Proximal Tibiofibular Joint Synostosis after Tibial Intramedullary Nailing

We report the case of a 28-year-old male semiprofessional basketball player who presented to an outside hospital with nonhealing stress fractures for which he underwent tibial intramedullary nailing (IMN). Two weeks after surgery, he developed pain proximal and lateral to the knee. As he returned to play, the pain worsened with jumping and lateral movement and improved with rest. He presented to our hospital one year after the operation with the same unresolved pain. Imaging one year after the surgery revealed proximal tibiofibular joint (TFJ) synostosis aligned with the drill path. Literature review showed that rare noncongenital cases of proximal TFJ synostosis cases were most often treated nonoperatively. However, two cases involved the removal of excessively protruding screws and two cases involved bone resection that resolved painful disruption of other joints, such as the ankle. The current patient had proper implant positioning and no other impacted joints, so he was managed without operative intervention. By the final 16-month postoperative follow-up, his symptoms had resolved completely. Although an unusual occurrence with limited data, we recommend nonoperative management for proximal TFJ synostosis caused by tibial nailing if implants are properly positioned and no other joints are affected.

A Comparison of the Open Semi-extended Parapatellar Versus Standard Entry Tibial Nailing Techniques and Knee Pain: A Randomized Controlled Trial

OBJECTIVE

To determine if an open, semi-extended, parapatellar tibial nailing technique (SEK) imparts any undue knee symptoms/pain compared with the traditional infrapatellar tibial nailing technique (FK).

DESIGN

Randomized controlled trial.

SETTING

Level 1 trauma center.

PATIENTS

Forty-seven patients with OTA/AO 42A-C tibial shaft fractures were included in the study.

INTERVENTION

Patients were randomized to treatment with either a SEK or an FK technique.

MAIN OUTCOME

The main outcome was a symptoms subset of the International Knee Documentation Committee (SS-IKDC) pertaining to knee symptoms/pain.

RESULTS

Final follow-up was collected at 1 year for 24 SEK and 23 FK patients. No significant differences were found between the groups in regards to demographics, injury, or surgery-related variables. The 2 techniques did have equivalent symptoms scores [mean for the difference (SEK - FK): 0.29, 90% confidence interval: -4.16 to 4.75] but did not have equivalent pain scores [mean for the difference (SEK - FK): 0.2, 90% confidence interval: -3.18 to 3.59]. When comparing demographic and injury-related variables to the SS-IKDC, only Kellgren-Lawrence classification was statistically significant (P = 0.026), where increasing presence of osteoarthritis was associated with lower scores.

CONCLUSIONS

The results of this single-center randomized controlled trial show that SEK and FK techniques for tibial nailing are equivalent in regards to knee symptoms (defined as ±5 points on the SS-IKDC) but not specifically pain that showed trends toward decreasing knee pain with the open SEK technique. This randomized controlled trial demonstrates that the use of the open semi-extended, parapatellar technique for tibial nailing should not be associated with any higher likelihood of knee pain/symptoms than the traditional flexed knee, infrapatellar technique.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Knee Pain After Intramedullary Nailing of Tibia Fractures: Prevalence, Etiology, and Treatment

Intramedullary nailing is often the treatment of choice for fractures of the tibia, but postoperative knee pain is common after this procedure. Potential etiologies include implant prominence, injury to intra-articular structures, patellar tendon or fat pad injury, damage to the infrapatellar branch of the saphenous nerve, and altered biomechanics. Depending on the etiology, described treatment options include observation, implant removal, assessment and treatment of injured intra-articular structures, and selective denervation. Careful attention to appropriate starting point and implant selection combined with more recently described semiextended nailing techniques may aid in prevention of knee pain.

Trajectory of Short- and Long-Term Recovery of Tibial Shaft Fractures After Intramedullary Nail Fixation

OBJECTIVE

To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals.

DESIGN

Prospective cohort study.

SETTING

A Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Center's prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years.

INTERVENTION

Enrolled patients were treated acutely with intramedullary nailing of their tibia.

MAIN OUTCOME MEASUREMENTS

Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA).

RESULTS

Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%).

CONCLUSIONS

The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Insertion-related pain with intramedullary nailing

The use of intramedullary nails for the treatment of long bone fractures has become increasingly frequent over the last decade with gradually expanding indications and technological advances. Improved biomechanics relative to plates and less direct fracture exposure are some of the potential benefits of intramedullary nails. However, persistent insertion-related pain is common and may limit satisfactory long term outcomes. The etiologies of this phenomenon remain unclear. Proposed theories for which there is a growing body of supporting evidence include hardware prominence, suboptimal nail entry points leading to soft tissue irritation and structural compromise, local heterotrophic ossification, implant instability with persistent fracture micromotion, and poorly defined insertional strain. Many factors that lead to insertion-related pain are iatrogenic, and careful attention to detail and refined surgical techniques will optimize outcomes.